When I was a junior surgical trainee, I was involved in a never event. For those who don’t know, a never event is an event that should, well, never happen. Like giving the wrong drug, or operating on the wrong side of the body.

This is a misnomer because, with varying frequency, they do happen.

The surgical WHO checklist has significantly reduced the number of never events that happen in operating theatres but, despite this, human error cannot be completely removed and the number never reaches zero.

In fact, after a few years, the number gradually begins to creep up again because the team relies on the checklist and stops actively thinking about it.

It is a difficult thing to accept that you have actually harmed a patient. No one sets out to do this but, either directly or indirectly, it is something that every doctor will do during their career. At medical school you are told that at some point you will fail, and every student in the room sits and thinks, "that won’t be me". But it will.

We often hear about another suicide of a junior doctor (female doctors are twice as likely to take their own life than the general population), and in most areas where I have worked there has been at least one or two. This trend is replicated in Australia and the US.

At the moment there is focus on the morale of the work force, particularly following the recent junior doctor contract negotiations. While it is undeniable that there are many environmental factors in the NHS that feed this (for ALL healthcare professionals, not just doctors), there is a more fundamental factor that is being ignored. We are not made to be resilient, and don't have the space to develop this quality.

Work environment, constant assessment and examination, and frequent moving between departments and hospitals during training can be damaging, not just to mental wellbeing, but also to patient care. One of the key determinants of a successful doctor-patient relationship, emotional intelligence, has actually been shown to decrease during training.

"It is difficult to accept that you have actually harmed a patient. No one sets out to do this but, either directly or indirectly, it is something that every doctor will do during their career."

We all knew what we were signing up for. Should we be surprised, then, that when people crack under the pressure, the fall is hard?

No.

Should this be the case?

No.

Resilience is the popular word at the moment, and courses are springing up to help doctors build theirs. But what does it mean, and what can we do until we have built it?

A recent definition I was given described resilience as being able to roll with the punches and get back to your feet after you go down, rather than being strong and simply breaking (ie being robust).

I was robust when I made my mistake, but I was fortunate to be surrounded by an incredibly supportive senior group who guided me through the root cause analysis process, and made me reflect on the experience, making changes to my practice that I will remember forever. They did it by telling me about their mistakes. Until that point, I had never heard a surgeon talk about making a mistake. I just believed it never happened, and that made me totally alone. Fortunately, I was wrong.

Talking about mistakes is crucial. Not only as a duty of candour to patients, but also to each other. Why? Because it is hard, and it is how we learn. Analysis and reflection on a negative event will often yield more benefit than learning from a positive one. Not only is there clinical advantage, and prevention of potential harm to patients, there is also the benefit of trusting relationships that arise from honesty between colleagues. Fostering an environment of psychological safety is crucial, allowing people to develop and ask questions without fear of embarrassment or reprimand.

I was fortunate to be in an environment where I could talk about my mistake and be guided in my learning from it. The experience changed my clinical practice forever and made me better equipped to support my colleagues. We may not yet be resilient, but we do have each other.

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Sounds like Human Factors. We do a lot if it in aviation - ultimately getting people to be open about their mistakes so that everybody can learn. I've cocked up in the air and, if there is no malice, the resultant chat with my boss (and then presentation to my Sqn) is more a (slightly embarrassing) learning experience than a bollocking! We combine it with the FAiR model (search MAA DA Fair in Google if you are interested) for determining culpability. Seems to work fairly well in my experience.

Having chatted to a bunch of the old boys on my side and then some of the doctors I know, it sounds like the NHS is slowly moving towards what we do, and you are where the RAF was 15 or so years ago. Articles like this can only help the change, good to read it mate.

An insightful and refreshing piece...a must for surgical trainees at every level. Surgical trainers "often ask learners to be vulnerable" and yet present themselves as high status, knowledgeable experts. Intellectual streaking (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3599294/#B25) - the exposure of a teachers thought processes, dilemmas or failures is a great way of modelling both reflection in action and resilience